Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Would you consider using acetazolamide to manage glomerular hyperfiltration in patients with type 1 diabetes, since SGLT2 inhibitors are contraindicated in this population?
Clever idea, but I think it is a bit much to assume that increased Na delivery from carbonic anhydrase blockade proximally would have the same renoprotective effect as an SGLT2i. So, no, I would not do this. However, I admire anyone thinking outside the box!
How has the FLUID trial, which showed no significant difference in death or readmission rates between Lactated Ringer’s solution and normal saline, influenced your approach to IV fluid management?
The choice between normal saline and Lactated Ringer's should be individualized. Normal saline is preferred in patients with hyponatremia or metabolic alkalosis. Lactated Ringer's is preferred in patients with hyperchloremic acidosis, and it should be avoided in patients with hyponatremia since its ...
Would you pursue a kidney biopsy in a patient with stable stage 1 AKI, bland urine sediment, and a positive MPO titer without systemic signs of vasculitis?
PR3-ANCA and MPO-ANCA are associated with substantially higher specificities and positive predictive values for ANCA-associated vasculitis (AAV) than the immunofluorescence patterns to which they usually correspond (C-ANCA and P-ANCA, respectively). However, false-positive results remain a concern. ...
Do you recommend fluid restriction in addition to other management strategies for patients with hyponatremia due to SIADH?
Fluid restriction is the mainstay of therapy in patients with SIADH. To correct hyponatremia due to SIADH, electrolyte-free water intake must be less than urinary electrolyte-free water excretion assuming no significant non-renal fluid losses. The degree of fluid restriction may be lessened by the u...
Do you apply manual pressure around the kidney biopsy site immediately post-procedure and prior to supine positioning to help prevent perinephric bleeding?
Yes, I do apply 3-4 minutes of manual pressure immediately at the site of a kidney biopsy while the patient is prone or supine if doing a transplant biopsy. I also apply a pressure dressing and have the patient lie down on it for 2 hours (for native kidney biopsies). This helps in a thin person.
Is it a good practice to prescribe clonidine to take as needed for occasional severe blood pressure elevations?
Prescribing as needed clonidine is not part of my routine BP management. If the BP is uncontrolled consistently then long-acting medications can be uptitrated or dose adjusted. As needed clonidine may be helpful in the initial evaluation period or when making medications changes. It is important for...
Do you counsel patients to take antihypertensives at specific times of day to maximize efficacy or minimize side effects?
I counsel my patients to take antihypertensives in the morning. The only exception is the alpha-1 antihypertensives. I use them only as an add-on, to be taken at bedtime for two reasons: one is to avoid the blood pressure surge in the early morning hours, and two is to minimize orthostatic blood pre...
Under what circumstances would you initiate hemodialysis for fetal protection in a pregnant patient with CKD Stage 4 who does not have any usual indications to start dialysis?
There is no one-size-fits-all approach. You do want to make sure the BUN does not get too high, which can be achieved with dialysis. Note that studies looking at very long dialysis times and treatment hours were for established dialysis patients. In patients with AKI or CKD stage 4, there is still s...
How do you approach the use of genetic testing in patients older than 30 years with resistant hypertension and hypokalemia, but with a normal aldosterone to renin ratio and no known family history of hypertension?
I am starting to use genetic testing more frequently now on patients like this, even though the absence of family history makes monogenic HTN less likely. Once other causes of hypertension with hypokalemia (Cushing syndrome, ectopic ACTH, licorice, etc.) are excluded, I think genetic testing may hel...
What is your approach to timing of the plasma, arterial, and venous urea collections in a patient on hemodialysis for whom you are attempting to calculate arteriovenous fistula recirculation?
I use the two-needle slow blood flow technique to calculate arteriovenous fistula recirculation: After initiation of hemodialysis, turn off ultrafiltration in approximately 30 minutes and then draw urea samples from the arterial and venous ports of the blood lines. Reduce the access blood flow rate...